Provider Demographics
NPI:1457502478
Name:SHAH, VICKI M (PA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:M
Last Name:SHAH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 W HARRISON ST STE 319
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3852
Mailing Address - Country:US
Mailing Address - Phone:312-942-8910
Mailing Address - Fax:
Practice Address - Street 1:1725 W HARRISON ST STE 319
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3852
Practice Address - Country:US
Practice Address - Phone:312-942-8910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL3270517Medicare PIN